Understanding the Bigger Picture: Harm Reduction & Social Determinants of Health

Now that we’re starting to get familiar with some of the terms used within trans communities, it is time to start thinking about the frameworks that we use to understand health. Discussions about trans people within medical discourse, the media, and academia are too often relegated to hormones and surgeries, that is, to the “physical” aspects of a transition. Trans people’s bodies and identities are therefore reduced to the status of their sexual organs, and their lives and realities are too often only understood within these terms. This kind of framework risks obscuring the ways in which institutional policies and social realities make the day-to-day lives of many trans people very difficult.

In order to approach trans health within a holistic framework, many allied professionals apply a harm-reduction approach, which recognizes the social, institutional, and economic circumstances that often result in a lack of access to basic services. Working from this approach, we can recognize that societal inequalities such as racism, poverty, ableism (discrimination against disabled people), social isolation, past trauma, and other forms of discrimination affect trans people and their access to medical and social services.  These inequalities also affect the ways in which trans people are able to find accurate information regarding surgeries and hormones, as well as their ability to afford all the financial and emotional costs of transition.

Take for example the case of poverty. Trans people are disproportionately affected by poverty. With a critical eye to the barriers in place that create situations of extreme poverty, as a provider, you can learn to more effectively advocate for your patient/client.

Some of the reasons trans people and poverty are often linked are

  • Barriers in obtaining and maintaining secure employment: A trans person may be discriminated against because they ask to be called a name other than that which appears on their legal identification documents, or because they are not always perceived by others as their chosen gender. Showing identification, and providing transcripts, diplomas, or references are all ways in which people are inadvertently forced to reveal the fact that they are or were undergoing sex/gender reassignment. This prevents many people from applying for jobs or, if they do, minimizes their chances of being hired.
  • Loss of family and community support: Some people lose the support of their family and friends after coming out. They can easily get kicked out of their parents’ homes, disowned, or cut off from financial support or access to the financial resources upon which they once relied. This kind of extreme loss could also result in depression, which can interfere with the ability to work.
  • Standards of Care: Up until the 7th version of the Standards of Care was released in the fall of 2011, the WPATH Standards of Care imposed strict limits on who was able to access hormones and surgery. While the current version of the Standards of Care are a vast improvement on previous editions, in order to access surgery, many transsexual people still have to undergo an extensive amount of therapy, ofen at great cost, as it is not covered by medicare. Some trans people have to pay more to access a support group or to receive a psychological evaluation. Many professionals charge exorbitant prices for their services and have no sliding scale fees based on income. The current version of the Standards of Care is much more flexible, has no minimum requirement for therapy, and encourages health care professionals to tailor the document to their patient’s individual needs.
  • The high cost of surgeries and necessary procedures: Although many trans-specific surgeries are covered in Québec, access to mental health professionals to write the letters of evaluation are a prohibitive cost for many. Furthermore, these surgeries are covered only for Québec residents with permanent immigration status, and many non-residents have to save for years to access them.
  • Other systemic barriers: Some trans people may be working under a name that is different from their legal name. They may have difficulty cashing personal cheques made out to their chosen name or even to their legal name. This can be very stressful because of the risk of being “outed.” Some trans people may not be able to access services because of their geographical location, because of the cost of transportation, or because of the cost of childcare. One way of helping with this is to be willing to see trans clients in their homes or to set up appointments in a way that maximizes the utility of their trip into your area.

While reading this guide, please try to keep in mind the various social and economic factors that limit access to essential services. This can mean considering, for example, how immigration policies can limit access to health care and social services, how changing legal documents to more accurately reflect one’s gender identity can help create the space for trans people to more safely navigate the world, and how trans people are often excluded from access to gender-segregated facilities (i.e. facilities that separate men and women), such as shelters and drug and alcohol detoxification/rehabilitation centres.

This information is far from exhaustive, but it is a starting point from which to get a glimpse into the harsh realities that some trans people face every day. As a service provider, you can advocate for your patients/clients by acknowledging the systemic barriers in place that prevent people from accessing services.

Applying a Harm Reduction Framework 

Harm reduction is a philosophy popularized by people organizing around HIV/AIDS and other health issues related to injection drug use. It aims to reduce the harm relating to high-risk behaviors, without pathologizing or criminalizing those who engage in these activities.  Harm-reduction work provides resources and options to drug users, to help make drug use a less risky activity, without trying to force users to stop this activity altogether.  This includes, for example, distributing clean needles to reduce the possibility of people sharing or reusing gear. Harm reduction philosophy positions drug users as the primary agents of reducing risk in their own lives, empowers users to make their own choices, and provides non-coercive and non-judgmental services.

This framework has since been adopted by many other health care and social service providers in a wide range of contexts. Working through a harm-reduction lens in its broadest sense means learning and understanding all of the social inequalities that act as barriers in access to services, and providing non-judgmental support. A health care or social service provider applying this framework follows the lead of their patient/client by providing resources that are relevant and respectful of a person’s individual needs, choices, and limitations.

  • Working from a harm reduction approach as a health or social service provider in a trans-specific context means;
  • Creating greater options for trans people to access Hormone Replacement Therapy. This can be done by using an informed consent model of care, which recognizes that your patient is best equipped to make decisions about their own body and life;
  • Acknowledging that trans people access hormones in a variety of ways, and that there are many people who find their hormones on the black market. As a health care provider, you can recognize and respect people’s choices and provide resources and support on safer use of street hormones;
  • Facilitating access to health care and social services to non-status trans people, and those whose immigration status is precarious;
  • Dispensing all pertinent information regarding risks and side effects of Hormone Replacement Therapy and Sex Reassignment Surgery for trans clients, in order for them to make informed decisions regarding their health;
  • Ensuring that people with a wide variety of gender identities and gender presentations routinely have a real voice in the creation of policies and programs designed to serve them;
  • Providing clear explanations of how to safely acquire, use, and dispose of syringes and intramuscular and intravenous needles;
  • Giving explanations of how to self-inject hormones safely;
  • Creating and distributing resources on safer drug use;
  • Consulting with peers to locate specialists who can provide services for your trans patients, including trans-positive gynecologists, endocrinologists, psychiatrists, and surgeons; and
  • Respecting and recognizing sex work as a legitimate form of employment. This can be done by respecting people’s choices, advocating for safer work conditions, supporting the decriminalization of sex work, and by providing relevant resources and support.